Workers Compensation

The v. 4.1 upgrade to WC UM 34 is a partner to the revision to WC UM 33 (see blog on that standard here). Like the WC UM 33 revision, this is billed as a "clarification of intent" standard. Also like the UM 33 revision, it is a significant clarification.

The 4.0 version read:

Standard appeals are completed, and written notification of the appeal decision issued, within 30 calendar days of the receipt of the request for appeal. (Primary)

The question not answered by this standard was "to whom does the notification go?" But then, one would have thought that WC UM 35 answered the question. That standard reads, in relevant part:

For appeals determinations, the organization issues written notification of the adverse appeal decision to the patient and attending physician or other ordering provider or facility rendering service . . ..

But this deals only with affirmations of non-certifications -- what about the appeals that overturn the "non-certs"?

URAC sorts it all out in the v. 4.1 WC UM 34:

Standard appeals are completed, and written notification of the appeal decision issued, within 30 calendar days of the receipt of the request for appeal to the patient and attending physician or other ordering provider or facility rendering service. (Primary)

In other words, the written notice of the appeal decision, no matter which way the decision goes, must be sent to both the patient and the provider.

The original, v. 4.0 version of this standard reads as follows:

Upon request from the patient, attending physician, or other ordering provider or facility rendering service, the organization provides specific clinical review criteria upon which the non-certification was based. (Primary)

URAC, in v. 4.1, substitutes "clinical rationale" for "clinical review criteria", so that the standard now reads:

Upon request from the patient, attending physician, or other ordering provider or facility rendering service, the organization provides specific clinical rationale upon which the non-certification was based. (Primary)

It would help, it seems to me, to lay out the URAC definitions of these terms:

• Clinical Rationale
  • A statement that provides additional clarification of the clinical basis for a non-certification determination. The clinical rationale should relate the non-certification determination to the patient’s condition or treatment plan, and should supply a sufficient basis for a decision to pursue an appeal.
• Clinical Review Criteria
  • The written screens, decision rules, medical protocols, or guidelines used by the organization as an element in the evaluation of medical necessity and appropriateness of requested admissions, procedures, and services under the auspices of the applicable health benefits plan.

This is a significant change, at least on its face. The two terms describe distinctly different concepts, and it would appear that v. 4.1 gives the applicant more leeway than v. 4.0. However, we've noticed that at least some URAC reviewers have been interpreting this standard more liberally than the narrow term "Clinical Review Criteria" would suggest, so it may be simply that URAC is bringing the standard into alignment with what has been the practice of the reviewers.